Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 5)

Administered by Department of Health, Disability and Ageing

Legislation au F2015L01711 Rules Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 5)

 

Authority

Section 333-20 of the Private Health Insurance Act 2007 (the Act) provides that the Minister may make Private Health Insurance (Benefit Requirements) Rules providing for matters required or permitted by Part 3-3 of the Act, or necessary or convenient to be provided in order to carry out or give effect to Part 3-3 of the Act.

 

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 5) (the Amendment Rules) consist of four Schedules (A, B, C and D), which amend Schedules 1-5 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.

 

Purpose

The purpose of the Schedule to the Amendment Rules is to amend Schedule 1 of the Principal Rules to insert one Medicare Benefits Schedule (MBS) item number.

 

Background

The Principal Rules, which commenced on 1 November 2011, provide for the minimum benefit requirements for psychiatric, rehabilitation and palliative care and other hospital treatment.  Schedules 1 to 5 of the Principal Rules set out the minimum levels of benefit which are payable for hospital treatment.  Namely, benefits for overnight accommodation (Schedules 1 and 2), same day accommodation (Schedule 3), nursing-home type patients (Schedule 4) and second tier default benefits (Schedule 5).

 

Schedule 1 categorises MBS item numbers into overnight patient classifications comprising ‘Advanced surgical patient’, ‘Obstetric patient’, ‘Surgical patient’, ‘Psychiatric patient’, ‘Rehabilitation patient’ and ‘Other patients’.  Schedule 3 sets out MBS item numbers for the same day hospital accommodation benefits which are payable for privately insured patients in all states and territories.

 

The minimum benefits payable per night for hospital treatment provided to NHTPs in Schedule 4 of the Principal Rules is subject to review and change twice annually, to reflect the indexation applied to the Adult Pension Basic Rate and Maximum Daily Rate of Rental Assistance.

 

Schedule 5 of the Principal Rules requires a health insurer to pay second tier default benefits for most episodes of hospital treatment provided in private hospital facilities that are specified in Schedule 5 if the health insurer does not have a negotiated agreement with the hospital.  Schedule 5 sets a higher minimum level of benefit (for overnight treatment and day only treatment provided in specified facilities) than the minimum benefit set for such treatment by Schedules 1, 2 and 3 of the Principal Rules.

 


Details

Details of the Amendment Rules are set out in the Attachment.

 

Consultation

 

In accordance with changes to the Health Insurance (General Medical Services Table) Regulations (GMST), one MBS item number has been added.  Medical advice was sought from within the Department regarding this amendment. No further consultation was undertaken because the amendment is minor in nature and does not significantly affect existing arrangements.

 

The Amendment Rules commence on 1 November 2015.

 

The Amendment Rules are a legislative instrument for the purposes of the Legislative Instruments Act 2003.

 

Authority: Section 333-20 of the

Private Health Insurance Act 2007

 

MEDICAL BENEFITS DIVISION

DEPARTMENT OF HEALTH

    OCTOBER 2015


Attachment

 
DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2015 (No. 5)

 

Section 1 Name of Rules

 

Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No.5) (the Amendment Rules).

 

Section 2 Commencement

 

Section 2 provides that the Amendment Rules are to commence on 1 November 2015.

 

Section 3 Authority

 

Section 3 provides that the Amendment Rules are made under item 3A of the table in section 333-20 of the Private Health Insurance Act 2007.

 

Section 4 Schedule

 

Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms. 

 

Schedules A, B, C and D

 

Schedules A, B, C and D provide that the Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on

1 November 2011.

 

Schedule – Amendments

Schedule 1, Part 2 – Type A Procedures, Clause 4, Advanced surgical patient, Subclause (3)

 

Item 1 amends Schedule 1, Part 2 – Type A Procedures, Clause 4, Advanced surgical patient, Subclause (3) of the Principle Rules by inserting one new MBS item numbers (37831).

 

MBS item 37831 is a new surgical item for the treatment of Hypospadias, staged repair, second stage, on a person under 10 years of age.

 

This item will be included in the GMST from 1 November, 2015.

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 5) were enacted under the authority of Section 333-20 of the Private Health Insurance Act 2007. These rules address a specific gap in the existing Private Health Insurance (Benefit Requirements) Rules 2011 by inserting a new Medicare Benefits Schedule (MBS) item number to cover a particular medical procedure. The rules were introduced by the Minister for Health and are aimed at ensuring that private health insurers provide adequate coverage for certain medical treatments. The rules amend the Principal Rules, which set out the minimum benefit requirements for various types of hospital treatment, to include a new MBS item number (37831) for the treatment of Hypospadias, staged repair, second stage, on a person under 10 years of age. This amendment ensures that the treatment is included in the General Medical Services Table from 1 November 2015, thereby updating the benefit requirements to reflect current medical practices and needs. The enacting body for these rules is the Minister for Health, who has the authority to make such rules under the Private Health Insurance Act 2007. The policy objective is to maintain and update the minimum benefit requirements for private health insurance to ensure that patients have access to necessary medical treatments. The amendment is considered minor and did not require extensive consultation beyond seeking medical advice within the Department, given its limited impact on existing arrangements. The rules are set to commence on 1 November 2015 and are a legislative instrument under the Legislative Instruments Act 2003.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 5) amends the Private Health Insurance (Benefit Requirements) Rules 2011, which set out the minimum levels of benefit that must be paid by health insurers for various hospital treatments. These amendments apply to private health insurers and the patients they insure, across all states and territories in Australia. The amendment specifically introduces a new Medicare Benefits Schedule (MBS) item number (37831) for the treatment of Hypospadias, staged repair, second stage, on a person under 10 years of age. This addition is intended to ensure that the minimum benefits for such treatments are covered by private health insurance policies, aligning with the changes to the Health Insurance (General Medical Services Table) Regulations. The amendment is minor and does not significantly alter existing arrangements, hence no further consultation was deemed necessary. The Amendment Rules commenced on 1 November 2015 and are a legislative instrument under the Legislative Instruments Act 2003.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 5) are amendments to the existing Private Health Insurance (Benefit Requirements) Rules 2011. These Amendment Rules primarily focus on updating Schedule 1 of the Principal Rules to include an additional Medicare Benefits Schedule (MBS) item number. Specifically, they insert MBS item number 37831, which pertains to the surgical treatment of Hypospadias, staged repair, second stage, for patients under 10 years of age. This addition falls under the classification of 'Advanced surgical patient' within Schedule 1, Part 2 – Type A Procedures, Clause 4, Subclause (3) of the Principal Rules. The Amendment Rules impose obligations on health insurers to ensure that they provide the specified minimum benefits as outlined in the updated Schedule 1. Health insurers must adhere to the new MBS item number and ensure that the corresponding benefits are included in their coverage for eligible patients. Additionally, these rules mandate that the second tier default benefits, as set out in Schedule 5, are applied to certain hospital treatments where no negotiated agreements exist between the insurer and the hospital. Failure to comply with the provisions of these Amendment Rules can result in civil and criminal consequences. Health insurers found to be non-compliant may face penalties under the Private Health Insurance Act 2007. The specific penalties for breaches of the benefit requirements are not detailed in the Amendment Rules themselves, but they generally include fines and potential legal actions against the non-compliant insurer. The maximum penalties for such breaches can be significant, reflecting the importance of adhering to the stipulated benefit requirements to ensure that patients receive adequate coverage and care.

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